This questionnaire is to illustrate some of the characteristics of how your mind - body responded to events.  Answer each statement as to how you generally feel when under stress.

SCALE:           
A.    Almost always                               
B.    Often   
C.    Sometimes               
D.    Almost never

_____    1.  Tend to think first of the negative things that are happening or may happen.

_____    2.  Notice my heart rate and/or breathing change.

_____    3.  Feel as if I had little control over what is happening.

_____    4.  Feel my muscles become tense and/or my hands tremble.

_____    5.  Feel I worry before a stressful event about how well I will do and/or after the event is over, I replay the situation.

______ 6.  Noticed that I perspire.

______ 7.  Become upset, distracted or confused when many activities or ideas are going on at the same time.

______ 8.  Feel knots in my stomach or became nauseous.

______ 9.  Become emotionally involved and can not concentrate on the immediate task.

______10.  Notice my hands and feet become cold.

SCORING:    Assign the following points to each question:   
A  = 4 points  
B =  3 points       
C =  2 point    
D = 1 point

Determine your cognitive  score by adding the total points from the odd numbered questions: questions  1,3,5, 7, 9 
COGNITIVE (mind) SCORE = ______________

Determine your somatic score by adding the total points from the even numbered questions:  questions 2,4,6,8,10 
SOMATIC (body) SCORE =  _______________

INTERPRETATION
Males and Females  -  Cognitive Anxiety
Low cognitive anxiety is  - 9 or below           
Average cognitive anxiety is - 10-14   
High cognitive anxiety is - 15 and above

Males
Low somatic anxiety is - below 7   
Average somatic anxiety is  - 8-12
High somatic anxiety is - above 13
       
Females    
Low somatic anxiety is -  below  9
Average somatic anxiety is - 10-14
High somatic anxiety is - above 15